Prophylactic Treatment of Migraine Headache

Migraine is a common disorder that affects 17 percent of women and 6 percent of men. Migraine prevention is multifaceted includes lifestyle modifications, migraine attack trigger identification and avoidance of risk factors, and, when indicated, medications, neurostimulation, and behavioral therapies.indications of preventive therapy Three or more moderate or severe headache days monthly causing functional impairment that are not responsive to acute treatments  At least 6 to 8 headache days per month even if acute medications are effective  Contraindications to acute migraine treatments  bothersome symptoms even if infrequent attacks (migraine with brainstem aura, hemiplegic migraine)  significant impact on patient’s life  risk of developing medication-overuse headache The goals of preventive therapy  Reduce attack frequency, severity and duration  Improve responsiveness to treatment of acute attacks  Improve function and reduce disability Pharmacologic preventive therapy  beta blockers, particularly metoprolol , propranolol , and timolol  calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs)  the tricyclic antidepressant amitriptyline(the only tricyclic that has proven efficacy)TCAs most commonly used include amitriptyline , nortriptyline , doxepin , and protriptyline .  serotonin/norepinephrine reuptake inhibitor venlafaxine  sodium valproate and topiramate  botulinum toxin is probably ineffective for the treatment of episodic migraine. In contrast, botulinum toxin type A injection is effective for the treatment of chronic migraine  erenumab, a CGRP receptor monoclonal antibody nonpharmacologic therapies  Relaxation training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive-behavioral therapy may be considered for migraine prevention.  classic acupuncture for migraine headache is more effective than placebo treatment Surgery  removal of muscle in trigger sites Patients with frequent migraine, identifiable trigger sites and positive response to botulinum toxin injection are candidates. The choice of prophylactic agent depends upon the individual situation, associated medical problems, and presence of conditions that are comorbid with migraine.